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Without Borders Podcast Dr. Tarun Dua March 27, 2017

Transcript – Dr. Kiran Thakur Interviewing Dr. Tarun Dua

Thakur: Welcome all and thank you for listening to the Neurology® Without Borders podcast. My name is Kiran Thakur, I’m an Assistant Professor in the Department of Neurology at Columbia University Medical Center in New York City and lead our Community and Global Neurology program here at Columbia. I’ve been fortunate to work with our speaker today on global public health activities for neurological disorders, and it’s really my distinct pleasure today to introduce Dr. Tarun Dua, a neurologist who serves as a focal point for neurological disorders in the Department of Mental Health and Substance Abuse for the World Health Organization in Geneva Switzerland. She’s lead several ground-breaking initiatives on behalf of the WHO, and just to name a few, led the first ministerial conference on global action in dementia; the development of MH GAP Guidelines on Mental, Neurological and Substance Abuse Disorders;the seminal publication on Public Health Challenges of Neurological Disorders; the WHO Atlas on Country Resources for Neurological Disorders; and work around the neurological complications of Zika virus. She’s indeed a very busy person, and we’d like to thank her today for taking time out of her schedule to speak with us about some of her public health activities as well as her background, which I think will be really interesting to listeners who have an interest in neurology as well as public health and global health activities—so thank you, Dr. Dua, for joining us.

I’d like to begin by asking you about your background in terms of where you grew up, your training, and how you became interested in public health as a neurologist and began working for the World Health Organization.

Dua: Thank you Kiran, and thank you for the introduction. I am originally from India, and I worked in a hospital and used to be part of a faculty at a medical college. And one of the things that I would see is the neglect within the community settings, within the public health settings, of the neurological aspects. For example, of conditions like epilepsy. Very often, children with epilepsy, because of the stigma attached to this disorder, will not get the treatment they need. Or, very often, the general practitioners or primary care physicians who would be working in general health settings, they will not be able to make any diagnosis of neurological disorders and shunt them away to specialists, which were far and few in many of the rural areas of India. So, that was one of the reasons that made me interested to think about the community aspects, the public health aspects, of neurology, and led to my work with the World Health Organization.

Thakur: And can you tell us about some of the activities of your job and the structure around the WHO as it relates to neurological disorders?

Dua: So, within WHO—you mentioned I work in the Department of Mental Health and Substance Use, but just to say that the areas we focus on include mental and brain disorders. One of the things within the World Health Organization that we focus on is around the public health aspects. We are not focusing on the basic science part or any of the clinical aspects, because we feel there are many centers, many organizations, and institutions involved in doing that work. The focus of our work is on public health, meaning understanding of: what’s the problem, and what kind of resources or services are available at country-level. Thinking in terms of simple guidance and prevention and management of neurological disorders in non-specialized settings. And this is important because, very often, if you look at some of the countries in Africa, there would be, for example, one to two neurologists serving a population of 25 million, and they would be sitting in the capital city. So clearly we need to involve the non-specialist much more than is currently happening. And foremost is to strengthen the capacities of countries, working with the policymakers to see that policies, plans, and implementation guidance to improve neurological care is happening at a national level, is happening at a regional level. And this is something that we do in collaboration with many partners, many stakeholders, including academic universities as well as non-governmental organizations.

Thakur: So you touched upon a lot of important aspects of your work in the WHO, and I was wondering if you could provide maybe an example or two of some of the work that you’ve done that maybe as an example of the efforts—to provide out listeners with some basic understanding of your role and how neurological disorders fits in with the work of WHO as a whole.

Many of you are aware that epilepsy is a very common neurological disorder. There are more than 50 million people worldwide who have epilepsy. Some of you may not know that the treatment gap for epilepsy—meaning people who have epilepsy and are able to get adequate and appropriate treatment—is very high. For example, in low- and middle-income countries, the treatment gap is as high as 75 percent. Now, that’s something that is unacceptable—should be unacceptable—because the treatment for epilepsy is inexpensive.

The treatment with the standard antiepileptic medications—if I take, for example, phenobarbital—can cost only 5 US dollars per person per year, but still there is a very high treatment gap. So, one of the things is the analysis of information: okay, what’s the burden? What’s the treatment gap? So that’s some of the things that we do. The second is then looking at the reasons of the treatment gap, and then working with the countries to—for example, if a guidance is required, coming out with guidance, or supporting countries to improve their systems. So if you look at, for example, the high treatment gap for epilepsy, you can look at the factors from supply side or demand side. And if you look at supply side, it’s because epilepsy is a very low priority. There is lack of infrastructure, there’s lack of trained personnel, and there’s lack of antiepileptic medication. So one of the things that we have been doing is having demonstrations projects—working within the countries to demonstrate the model of care; where we have—focusing on increasing the prioritization of epilepsy within the country’s healthcare system; a system of training the primary health care providers; involving communities; improving awareness and understanding; and then to see: are we able to make a difference? And this has—you know, for example, if I take the example of the project in China, the treatment gap reduced by 13%, which was a statistically significant difference.

And we have been adapting and replicating this model in many countries in Asia and Africa. And trying to mainstream, or trying to integrate epilepsy management within the country’s health care system, which is extremely important if the treatment has to be brought closer to the people, where they live. And some of the things that we hear from—for example, on visits to these sites, tell us really the importance of working at community level, working within these low-resource settings. So, for example, one of the projects in Vietnam, and one of—the person we were talking to, she was saying that every time going to the hospital for her medication, every month, it was like, four hour’s journey—it was quite a big deal for her. Then, some of the settings—for example, I take the example of Ghana, where we worked—there, many patients would go first to a traditional healer, or a faith healer, rather than going to the hospital. So they told us that first they would try to cure them themselves, like going to the traditional healers, but then they saw after we implemented the project and they went to the hospital or the health facility—they realized that they could benefit much more. So these are some of the things that we are working with the countries to improve access and care to services. So, this is an example of the kind of work we have done. And the guidance that is provided to countries is something that has been part of our evidence-based guidance. We have simple clinical algorithms that non-specialists can use. So these are some of the tools that are available from the World Health Organization to be used by any primary health care provider in any country—[provided to] any of the program managers to implement such a system and implement a strategy.

Thakur: Yeah, I think that’s a really important example that you describe, and I just returned from Malawi, in which there’s a major issue with the availability of antiepileptic medications, and had to try to figure out how to manage patients when there’s, you know, one or two of the three available antiepileptics available at a particular time. So we see patients coming in with severe burns, and having had accidents related to the lack of control of their seizures. So I think that’s a very good example that you describe, and, I think, really important work.

In terms of other priorities, we talked about epilepsy and the treatment gap, but if you could describe, I think, some of the major current priorities that the WHO has for neurological disorders and how you are kind of working around those efforts currently, I think that would be good for the listeners to hear about.

Dua: Okay, so, I can talk about a couple of things, but since you mentioned Zika virus, I would mention that, because that’s a unique aspect of neurology. So, as was covered by media quite a bit, it was in 2015 that there was an unusual association between microcephaly and Zika virus exposure that was discovered in Brazil, and it led to the declaration by the World Health Organization of a public health emergency of international concern in February 2016, one year back. What it means is that—in simple terms, it means that all countries need to think about Zika virus. It could spread anywhere, and that was the main challenge.

Now, we have heard of previous public health emergencies—the one that comes to my mind is Ebola—and the difference between the Zika virus emergency and the Ebola emergency was the consequences—the aspect of the condition that caused the emergency. And it was not because Zika virus was killing people; it was because many children were born with microcephaly, or there were many cases of Guillain-Barré syndrome. Now, this was one of the few, very rare cases that the neurological complications or the neurological manifestations were the cause of the emergency.

And so, what it required of the countries—[they] were unprepared. For example, some of the systems in these countries, taking simply in many of the low- and middle-income, taking a head circumference is a difficult task. That’s the simplest of the tasks, but they are not trained to do that. Then, if you come into terms of neuro-imaging, there are very few CTs or MRIs available, which are required because many of these kids had brain abnormalities. Then come in other aspects of neurological manifestations, and similarly, if you take Guillain-Barré syndrome in adults, there were clusterings of Guillain-Barré cases. The primary health care providers are not trained to detect and diagnose Guillain-Barré syndrome. The infrastructure is not available to manage Guillain-Barré syndrome. So it really—this condition, it emerged as one reviews the information, that the countries are not prepared and there isn’t sufficient capacity at country level to deal with such emergencies, such neurological problems.

So, one of the first things that they did in WHO was to develop emergency guidelines and, Kiran, on the other end of this interview, worked with us on developing those guidelines. And these were important for countries to take forward. And then, we are now then working further on a toolkit, which provides information on how, for example, a program manager who has to think about (even if it’s not a problem) how to organize the response, a training package, for health care providers and support at community level, because if you think in terms of a spectrum of abnormalities that are happening, you have to think in terms of providing support to the parents of these babies—the mental health and psychosocial support that is required.

So this brings in the concept of the comprehensive multi-disciplinary team. And the implementation at the primary health care level and peripheral to other specialists, such as ophthalmologists, such as an ENT specialist, that is required to detect many of these problems. So, this is, again, an area of work where I, along with many other colleagues, have been involved. And raising the importance of diagnosing, managing, and the issue of having adequate availability of services for people with neurological disorders.

Thakur: Do you think that the Zika virus epidemic, from a public health standpoint, has raised awareness in terms of some of the challenges that exist with neurological care and global public health? You touched upon a lot of the aspects that are needed in terms of care of those infants, as well as children and adults who may be affected by the neurological complications, and I think it probably touches upon some of the themes that relate to treatment of neurological disorders, particularly in low- and lower middle-income countries, including access to medication, the lack of a neurological workforce, tools to assess patients, the stigma associated with the conditions—did you think that it’s changed outlook in terms of neurological disorders for maybe those who are non-neurologists at all? In terms of public health personnel?

Dua: I think so, and I believe so. I think there has been increased recognition of neurological disorders in the mind of many of the policymakers. I think the point I would like to make here is that it is very sad that many of the kids have been born with this syndrome, or the adults have had Guillain-Barré syndrome, but how this can be an opportunity within the countries to strengthen neurological care. Because it’s an opportunity to think about how we can increase the capacity of the workforce, increase the capacity of the infrastructure that exists in the country to deliver better neurological care. And that can only happen if we have a global neurology movement, and not thinking in terms of neurological care that is bound only to the tertiary care or bound only to the specialists. It’s very critical that we think about how we can take neurological care to the primary health care system. Because for many patients, for many people, primary health care is the way forward, and unless and until we try to have that kind of a movement, have that kind of momentum in neurology, we will not be able to reach and decrease the treatment gap that I talked about earlier—epilepsy at 75 percent, and in many of the neurological disease it might be much more, because these are not even recognized conditions in many of the communities.

Thakur: I think that’s a very important point. What do you see as the barriers to this type of movement, or do you think that it’s something that is propagating and moving forward in terms of advocating and pushing neurological care on a global scale?

Dua: I think things are changing. I think many people are recognizing the importance of neurological disorders. Many countries are recognizing the importance of neurological disorders. So for example, going on to the other end of the life course—taking the example of dementia, very recently, all countries requested WHO to develop an action plan on public health response to dementia and the support. And what we heard from the different countries was that it’s not only a problem in high-income countries; it’s a problem in low- and middle-income countries, and they are requesting WHO for technical support to help them develop policies, help them have guidance and tools to strengthen their health and social care system to take better care of people with dementia. And it’s not only about having research finding treatment; it’s about how better care can be provided, how people can be supported, how their caregivers can be supported. So I think things are changing; I think the neurology community as well as the public health community needs to work together to see that we are able to reach people who need care the most.

Thakur: And—true, and I think a lot of people, maybe outside of neurology, have a conception that both pediatric and adult neurology is a very subspecialized field and may not necessarily be applicable to global health. I think those of us in the field, both in public health as well as doing clinical work and research really know otherwise, but how do you kind of spread that word and raise awareness? I mean, we’ve talked about this a little bit, of—what are the next steps, from a—not kind of conceptualizing idea of this global health movement, but what do we do going forward in terms of concrete ideas?

Dua: I think it requires a kind of a multi-prong strategy, and all of us have a role to play. So for example, the role that academic universities can play is to have a global or a public health neurology program. The other thing could be having a short course on global neurology or public health neurology so that people are sensitized. The third thing that can happen is that, for example, the undergrad curricula, or the post-grad curricula, depending on wherever, you know, for different specialties, even for neurologists, that the public health aspects are considered. So, these are some of the things that we can have, involve the universities, the non-governmental sector, the associations, the scientific associations have a role to play. Very few conferences, for example, will have a session around public health neurology, and even if they have a presentation, not many people come. But I think what is required is that whenever there are any opportunities for disseminating information, advocating for public health neurology, we should be doing that, and I see this interview as an example of doing that. So hopefully this message will go to many neurologists and many public health specialists to think about these neglected conditions—but also how much can be done to support these people with neurological disorders and their families.

Dua: Good. And just to kind of end, what advice would you give to an individual whose training and interested in public health activities and global health as it relates to neurology? A lot of people often ask you, I’m sure, for advice and how to become involved. What would you tell our audience of younger trainees in terms of how to pursue their interests?

Dua: I think there are various opportunities. One is, of course, they can always be in touch with us at WHO. They can also be in touch with some of the public health neurology programs and different academic universities where they can get better guidance. We have material available on our website. Then there are examples of North-South collaborations. I think working in one of the low- and middle-income country settings, or the low-resource settings, would help one understand. And I feel I need to say low-resource settings; it’s not only low- and middle-income countries, I think—it’s also the rural settings, remote settings, or even now, looking at some of the countries—even the migrant populations, the refugees. So there are lots of settings where the principles of public health neurology can be applied, and I think I would encourage that all curricula should have, you know, whatever hours can be devoted, to be devoted to public health neurology.

Thakur: I mean, that’s a great point, and I remember early on in my training, I worked on a Native American reservation, and we often talk here at Columbia, our local population, which is definitely in need and has a lot of parallels with populations that I take care of in various countries, so I think that’s a great point, and a lot of good examples in terms of how trainees can be involved.

I’d like to thank you for this conversation, and if you have any final words of wisdom—you know, I think you’re a mentor to many of us, and I think a leader in this field, and pushing the movement forward. We really appreciate this conversation and the time you’ve spent with us today.

Dua: Thank you, Kiran; thank you for giving me the opportunity to reach out to this audience, and I think I would encourage everybody to run things in terms of, you know, you have extracurricular activities or some kind of voluntary activity—think of public health neurology as one of the activities that you have. Let it be part of your bucket list. Do it at least, you know, once, and if you can, at least once every year. It’s going to be fulfilling, I can promise you that.